Form ECY040-1-100 "Voluntary Relinquishment of Water Right Certificate" - Washington

What Is Form ECY040-1-100?

This is a legal form that was released by the Washington State Department of Ecology - a government authority operating within Washington. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2015;
  • The latest edition provided by the Washington State Department of Ecology;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form ECY040-1-100 by clicking the link below or browse more documents and templates provided by the Washington State Department of Ecology.

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Download Form ECY040-1-100 "Voluntary Relinquishment of Water Right Certificate" - Washington

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Department of Ecology
Water Resources Program
Voluntary Relinquishment of a Water Right
Check appropriate boxes below
Full Relinquishment
Partial Relinquishment
Surface Water
Groundwater
Reservoir
Contact Name:
Water Right Number:
Address:
City:
State:
Zip:
E-mail Address:
Telephone Number:
Full Relinquishment
I (we) relinquish Water Right Number
to the State of Washington.
Partial Relinquishment
I (we) relinquish a portion of Water Right Number
described as
follows: (Describe quantity, purpose, place of use to be relinquished).
Legal Description of the Place of Use: (This information may be found on a real estate contract,
property deed, or title insurance policy).
¼
¼
Section
Township
Range
County
Parcel Number
ECY 040-1-100 (Rev 05/2015) To request ADA accommodation including materials in a format for the visually impaired, call Ecology Water
Resources Program 360-407-6872. Persons with impaired hearing may call Washington Relay Service at 711. Persons with speech disability
may call TTY at 877-833-6341.
Department of Ecology
Water Resources Program
Voluntary Relinquishment of a Water Right
Check appropriate boxes below
Full Relinquishment
Partial Relinquishment
Surface Water
Groundwater
Reservoir
Contact Name:
Water Right Number:
Address:
City:
State:
Zip:
E-mail Address:
Telephone Number:
Full Relinquishment
I (we) relinquish Water Right Number
to the State of Washington.
Partial Relinquishment
I (we) relinquish a portion of Water Right Number
described as
follows: (Describe quantity, purpose, place of use to be relinquished).
Legal Description of the Place of Use: (This information may be found on a real estate contract,
property deed, or title insurance policy).
¼
¼
Section
Township
Range
County
Parcel Number
ECY 040-1-100 (Rev 05/2015) To request ADA accommodation including materials in a format for the visually impaired, call Ecology Water
Resources Program 360-407-6872. Persons with impaired hearing may call Washington Relay Service at 711. Persons with speech disability
may call TTY at 877-833-6341.
Do you own all the land in the place of use?
Yes
No
If no, provide the following:
Owner Name(s):
Address:
State:
City:
Zip:
E-mail Address:
Telephone Number:
I (we),
, am (are) the holder(s) of the above referenced water
right.
The following statements are true, to the best of my knowledge:
I (we) are not aware of any changes, sales, or transfers of this water right to another party.
I (we) have no further requirement to put to beneficial use any or the portion of the water right
described above.
I (we) agree to relinquish all or the portion of the water right described above.
I (we) understand that based on the above information the Department of Ecology may issue an
Order of Relinquishment.
Signature(s):
Date:____/_____/_____
Date:____/_____/_____
State: ___________________________
}
§
County: __________________________
I hereby certify that I know or have satisfactory evidence that
__________________________________________________________________________________
is (are) the person(s) who appeared before me, and said person(s) acknowledged that he/she signed this
instrument and acknowledged it to be his/her free and voluntary act for the uses and purposes
mentioned in this document.
Dated:
day of
,
.
Notary Printed Name:
Seal
My Appointment Expires:
or
______/______/______
Stamp
Notary Public Signature:
ECY 040-1-100 (Rev 05/2015) To request ADA accommodation including materials in a format for the visually impaired, call Ecology Water
Resources Program 360-407-6872. Persons with impaired hearing may call Washington Relay Service at 711. Persons with speech disability
may call TTY at 877-833-6341.
Submit this form to the Regional Office serving your area:
Central Regional Office
Northwest Regional Office
1250 W. Alder Street
3190 – 160th Avenue SE
Union Gap, WA 98903-0009
Bellevue, WA 98008-5452
(425) 649-7000
(509) 575-2490
Eastern Regional Office
Southwest Regional Office
4601 N. Monroe Street
PO Box 47775
Spokane, WA 99205-1265
Olympia, WA 98504-7775
(509) 329-3400
(360) 407-6300
ECY 040-1-100 (Rev 05/2015) To request ADA accommodation including materials in a format for the visually impaired, call Ecology Water
Resources Program 360-407-6872. Persons with impaired hearing may call Washington Relay Service at 711. Persons with speech disability
may call TTY at 877-833-6341.
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